Randomized comparison of defibrillation thresholds from the right ventricular apex and outflow tract

Background Implantable cardioverter-defibrillator (ICD) leads are traditionally placed in the right ventricular apex (RVA), in part because this is considered the preferred vector for minimizing defibrillation threshold (DFT). However, if adequate DFT safety margins are attainable, ICD leads placed in the right ventricular outflow tract (RVOT) might confer advantages if frequent ventricular pacing is anticipated. Objective The purpose of this study was to compare RVA with RVOT transvenous ICD lead position on DFT. Methods This was a prospective, randomized, crossover study of RVA versus RVOT DFT in 33 patients undergoing left pectoral ICD placement. A binary search algorithm was used to measure DFT, with initial lead position tested in randomized order. The relationship between RVOT position and DFT was assessed by evaluation of the distance between RVA and RVOT. Results The study population had a mean age of 59 ± 12 years and ejection fraction of 33% ± 14%. Mean DFT in the RVA was 9.8 ± 7.3 J versus 10.8 ± 7.2 J in the RVOT ( P = .53), with no correlation between RVOT location and DFT. Conclusion The study found no evidence that ICD lead placement in the RVOT is associated with significantly higher DFT than lead placement in the RVA.